A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?
Place the client upright on a donut-shaped cushion.
Turn and reposition the client every 15 minutes while sitting.
Apply a moisture-barrier cream to the affected area.
Turn and reposition the client every 3 hours while in bed.
The Correct Answer is B
Choice A rationale: Donut-shaped cushions are contraindicated because they create a ring of high pressure that restricts blood flow to the central area. This can worsen tissue ischemia and accelerate skin breakdown.
Choice B rationale: Clients with paraplegia sitting in a chair should be repositioned every 15 minutes to relieve pressure. Frequent shifts are necessary because sitting exerts higher pressure on the ischial tuberosities than lying down.
Choice C rationale: Moisture-barrier creams are used to protect skin from incontinence or wound drainage. Nonblanchable erythema indicates a stage 1 pressure injury, which requires pressure relief rather than a topical moisture barrier.
Choice D rationale: While in bed, the standard of care is to turn and reposition the client at least every 2 hours. A 3-hour interval is too long and increases the risk of further tissue damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Contractions lasting 60 seconds every 5 minutes are normal for active labor, indicating effective uterine activity to progress delivery. This does not require immediate reporting, as it aligns with expected labor patterns and does not indicate fetal or maternal distress, making it a non-urgent finding.
Choice B reason: A fetal heart rate of 140 beats per minute is within the normal range (110-160 bpm) for a fetus in labor. This indicates fetal well-being and does not require reporting unless accompanied by abnormal patterns like decelerations, making this finding normal and not urgent.
Choice C reason: A maternal blood pressure of 120/80 mmHg is normal and does not indicate distress or complications like preeclampsia. It does not require reporting, as it reflects stable maternal hemodynamics during labor, making this finding non-urgent compared to fetal heart rate abnormalities.
Choice D reason: Late decelerations in the FHR indicate uteroplacental insufficiency, reducing fetal oxygenation and risking hypoxia. This requires immediate reporting to the provider for interventions like position changes or oxygen administration to prevent fetal distress, making it the critical finding necessitating urgent action.
Correct Answer is B
Explanation
Choice A reason: Decreased BUN is not typical in preeclampsia, where renal impairment often elevates BUN due to reduced glomerular filtration. Normal or increased BUN is expected, so this finding does not align with preeclampsia’s pathophysiology, making it an incorrect expectation.
Choice B reason: Increased protein in urine (proteinuria) is a hallmark of preeclampsia, resulting from glomerular damage due to hypertension and endothelial dysfunction. This diagnostic criterion, often >300 mg/24 hours, is critical for identifying preeclampsia, making it the correct finding the nurse should expect.
Choice C reason: Increased platelet count is not associated with preeclampsia, which often causes thrombocytopenia due to endothelial activation and platelet consumption. A decreased count (<100,000/mm³) is more likely, making this finding incorrect for preeclampsia’s clinical presentation.
Choice D reason: Decreased serum uric acid is not expected in preeclampsia, where elevated uric acid occurs due to reduced renal clearance from glomerular dysfunction. Increased levels are a marker, so this finding is opposite to preeclampsia’s effects, making it incorrect.
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